Introduction

Aim

Definition of terms

Assessment

Management

Notes

Links

References

Evidence Table

Introduction

Anaesthetic and surgical staff are often presented with children who have recently been immunised, for either emergency or elective surgery. Although there is no direct evidence of any major interaction between immunisation and commonly used anaesthetic agents and techniques in children, it is possible that the anaesthesia or surgery may affect the immune response of the vaccine. It is also possible that the systemic effects from immunisation, such as fever, may confuse the clinical management of the patient during the post-operative period. It is therefore important that an immunisation history is undertaken prior to surgery. 

Aim

The aims of this guideline are:

• To inform medical and nursing staff about practice regarding the timing and side effects of immunisation with respect to general anaesthesia and surgery.
  
• To recommend circumstances where a patient could receive vaccination whilst under general anaesthesia.
  
• To outline the steps of getting a patient vaccinated under general anaesthesia if indicated.
  
• To indicate if scheduled immunisation should be delayed if a child has had either elective or emergency surgery.
  

Definition of terms

• AIR – Australian Immunisation Register
  
• Anaesthesia – insensitivity to pain, especially as artificially induced by the administration of gases or the injection of drugs before surgical operations. 
  
• EMR – Electronic Medical Record
  
• Immunisation – the process of inducing immunity to an infectious agent by administering a vaccine.
  
• Inactivated vaccine –  the viruses or bacteria in vaccines are completely inactivated (or killed) with a chemical and that they cannot reproduce themselves or cause disease but are still recognised by the body's immune system to achieve immunity. 
  
• Live attenuated vaccine –  the live viruses used in vaccines are weakened (or attenuated) and they replicate themselves just well enough to cause the immune system to produce protective antibodies. 
  
• Needle phobia – severe fear of medical needle procedure and/or recent prior failure to vaccinate due to severe fear or distress of the procedure. 
  
• NIP – National Immunisation Program
  
• Vaccination – the administration of a vaccine; if vaccination is successful, it results in immunity. 
  

Assessment

• Pre-assessment of patients who are going for surgery to be done by the Nursing Care Coordinator (e.g. Complex Care team, Pre-admission Resource Centre) at least one day before the surgery to determine if the patient requires vaccination under general anaesthesia.
• If yes, inform the surgical team and the anaesthetist and arrange with the RCH Immunisation Centre.
• For day cases admitted through Day of Surgery, an admission assessment should be completed by the nurse with a parent or care giver.
• Once the patient’s immunisation status is checked, the nurse should document if a patient is up to date with vaccination as well as if a patient has received a live attenuated parenteral vaccine in the last 7 to 10 days or an inactivated vaccine within 48 hours of the planned surgery.  
• If the patient has received a vaccine, the surgical team should be advised.
• If upon pre-operative assessment, you determine the patient requires immunisation, then discuss with the surgical staff a plan for vaccination.  
• The vaccines can be administered upon discharge at the RCH Immunisation Drop-in Centre, at a follow-up outpatient appointment at RCH, or via the patient’s General Practitioner.
  

Management

Pre-operative / Intra-operative

As both anaesthesia and surgery may impair the immune system, there is the theoretic risk of altered response to vaccines if surgery is performed in close proximity to vaccine administration In general, immunisation should not be administered during general anaesthesia, in order that paracetamol or other anti-inflammatory agents can be used freely as part of the anaesthetic technique and post-surgical care. If it is indicated immunisation should be given when the child has recovered, but before discharge.   
However, there may be circumstances where vaccination under general anaesthesia may be the best option for the patient.  Specifically:

• Patients with developmental or behavioural disorders (such as autism spectrum disorder);
• Children and adolescents with extreme anxiety or needle phobia;
• Patients requiring four (4) or more injections.
  

In situations where intra-operative vaccination is required, this is to be negotiated with the Royal Children’s Hospital (RCH) Immunisation Centre nursing staff and the surgical staff prior to the patient entering the Operating Suite. This can be via the Nursing Care Coordinator (e.g. Complex care team, Pre-admission Resource centre).  Steps:

1. Inform the nursing staff of RCH Immunisation Centre one day before the patient’s surgery or procedure under general anaesthesia (or on Friday if the surgery is on the following Monday);
   
2. Consent for vaccination under general anaesthesia needs to be documented on the Consent Form;
   
3. Nursing staff of RCH Immunisation Centre need to go through the pre-vaccination screening checklist and discuss the vaccine side effects with the parent/carer prior to vaccination;
4. Anaesthetist or anaesthetic technologist  contacts the RCH immunisation Centre ten (10) minutes prior to taking the patient into the Induction Room;
   
5. Nursing staff of RCH Immunisation Centre administers vaccinations according to the Clinical Practice Guideline on Immunisation of Inpatients once the patient is anaesthetised.
   
6. If the RCH Immunisation service staff are unable to administer the vaccine(s) due to time constraints, then theatre medical or nursing staff can administer if the vaccine is prescribed in the EMR.

Please note:

• Recent immunisation does not impact upon the outcome of surgery.
• Possible side effects such as mild fever, irritability or sleepiness may occur up to 48 hours following immunisation with inactivated vaccines, or high fever around 7 to 10 days following immunisation with live attenuated vaccines. This is more likely to be a real problem following major surgical procedures, as fever and malaise may cause confusion in the post-operative period.
• Record date of recent vaccination in the Nursing assessment and inform surgical and anaesthetic staff so that this can be taken into account when managing the patient post-operatively.

Documentation of vaccination: 

All vaccines administered to patients should be documented in the patient’s EMR and the individual child health record or immunisation record card.

Post-operative 

• There is no contraindication to immunisation immediately after surgery, once the child is well and has recovered from the procedure.  
  
• Delaying immunisation increases the risk of infection in the affected child, and has been shown to result in non-completion of the immunisation schedule in some children. The importance of completing the immunisation schedule both for the child and the community outweighs any concerns about the impact of immunisation upon surgery and the impact of surgery upon immunisation. 
  

Notes

RCH Immunisation Drop-in Centre opens from 9:00am - 4:30pm Monday to Friday (except public holidays). Phone: 93454899

Links

• Australian Immunisation Handbook
  • Pre-vaccination screening checklist (Table 2.1.1)
  • Live attenuated parenteral and oral vaccines (Table 2.1.3)
• Association of Paediatric Anaesthetists - The timing of vaccination with respect to anaesthesia and surgery
• NIP Schedule 2016

References

• Association of Paediatric Anaesthetists of Great Britain and Ireland. (2010). Immunisation guideline: The timing of vaccination with respect to anaesthesia and surgery. Retrieved from https://www.apagbi.org.uk/sites/default/files/inline-files/Final%20Immunisation%20apa.pdf 
  
• Australian Government Department of Health (2020).  The Australian Immunisation Handbook. Retrieved from https://immunisationhandbook.health.gov.au/ 
  
• Bertolizio, G., Astuto, M., and Ingelmo, P. (2017).  The implications of Immunization in the daily practice of pediatric anesthesia.  Current Opinion in Anesthesiology, 30(3), 368-75. doi: 10.1097/ACO.0000000000000462 
  
• Crowcroft, N.S., & Elliman, D. (2007). Vaccination and anesthesia: the precautionary principle is to vaccinate. Pediatric Anesthesia, 17(12), 1216-1218. doi: 10.1111/j.1460-9592.2007.02360.x
  
• Currie, J. (2006). Vaccination: is it a real problem for anesthesia and surgery?. Pediatric Anesthesia,16(5), 501-503. doi: 10.1111/j.1460-9592.2006.01898.x
  
• Lonsdale, H., & Sivaprakasam, J. (2014, June). Immunisation and general anaesthesia – audit of practice in a specialist paediatric hospital. Paper presented at the AAGBI GAT Annual Scientific Meeting, Newcastle upon Tyne, UK. Abstract retrieved from http://onlinelibrary.wiley.com/doi/10.1111/anae.12765/pdf 
• Nafiu, O. O., & Lewis, I. (2007). Vaccination and anesthesia: more questions than answers. Pediatric Anesthesia, 17(12), 1215. doi: 10.1111/j.1460-9592.2007.02318.x
  
• Pandey, R., Garg, R., Darlong, V., & Punj, J. (2008). Vaccination and urgent surgery in children: anesthetic concerns. ACTA Anaesthesiologica Taiwanica, 46(4), 199-200. doi: 10.1016/S1875-4597(09)60011-4Popa, A., Malos, A., & Cernea, D. (2009). Recently immunization and anesthesia of the children. Current Health Sciences Journal 35(3), 201-204. Retrieved from http://www.chsjournal.org/archive/vol-35-no3-2009/for-practitioner/recently-immunization-and-anesthesia-of-the-childreShort, J. A., van der Walt, J. H., & Zoanetti, D. C. (2006). Immunization and anesthesia – an international survey. Pediatric Anesthesia, 16(5), 514-522. doi: 10.1111/j.1460-9592.2006.01897.x
  
• Short, J. A., van der Walt, J. H., & Zoanetti, D. C. (2007). Author’s reply. Pediatric Anesthesia, 17(12), 1215-1216. doi: 10.1111/j1460-9592.2007.02321.x
  
• Siebert, J. N., Posfay-Barbe, K. M., Habre, W., & Siegrist, C. A. (2007). Influence of anesthesia on immune responses and its effect on vaccination in children: review of evidence. Pediatric Anesthesia, 17(5), 410-420. doi: 10.1111/j1460-9592.2006.02120.x
  
• Siebert, J., Posfay-Barbe, K. M., Habre, W., & Siegrist, C. –A.(2007). Pediatric Anesthesia, 17(12), 1218-1220. doi: 10.1111/j.1460-9592.2007.02369.x
  

Evidence Table

Immunisation and Anaesthesia Evidence Table

Please remember to  read the disclaimer . 

The development of this clinical guideline was coordinated by Sonja Elia, Nurse Practitioner, Immunisation . Approved by the Clinical Effectiveness Committee. Updated August 2020.